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Wallace, William NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit ve.. Name First Middle Last Sex ::"'' William Wallace Male r Date of Death Age If Veteran of U.S. Armed Forces, :: March 28, 2016 B5 War or Dates NA ':: Place of Death: h Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending 13. Circumstances Investigation Medical Certifier Name Title Scott Biasetti MD 0:: Address 100 Park St.Glens Falls,NY ; Death Certificate Filed District Numb Registe u er fir City, Town or Village Glens Falls, NY s-j Q 1 / 0 Burial Date Cemetery or Crematory March 30, 2016 Pine View Cemetery E Entombment Address ❑Cremation Quaker Road Queensbury, Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address F Hold Cl) 0 Date Point of NTransportation Shipment Q by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address : Permit Issued to Registration Number : ; Name of Funeral Home Regan Denny Stafford Funeral Home 01443 };r Address 1. 53 Quaker Road, Queensbury, NY 12804 ti•: Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above I.. Address Z::,' Permission is hereby granted to dispose of the human remains described above as indicated. r` Date Issued 31 ZG 1 2.0I-6 Registrar of Vital Statistics L'•D 1.,.Q, �. (signature) Fg:: District Number 5 6©) Place 6 sio,kis y I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z w Date of Disposition 3/30/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY 2 (address) W N Erie 44D 1 CL (section) (lot number) (grave number) pName of Sext or Person in Charge of Premises Connie L. Goedert Z C C� (please print) W Signature kit i �./Z.Q Title Cemetery Superintendent /�J (over) DOH-1555(02/2004)